Risk factors for complications associated with upper gastrointestinal foreign bodies

AIM: To investigate predictive risk factors associated with complications in the endoscopic removal of foreign bodies from the upper gastrointestinal tract.METHODS: We retrospectively reviewed the medical records of 194 patients with a diagnosis of foreign body impaction in the upper gastrointestinal tract,confirmed by endoscopy,at two university hospital in South Korea.Patient demographic data,including age,gender,intention to ingestion,symptoms at admission,and comorbidities,were collected.Clinical features of the foreign bodies,such as type,size,sharpness of edges,number,and location,were analyzed.Endoscopic data those were analyzed included duration of foreign body impaction,duration of endoscopic performance,endoscopic device,days of hospitalization,complication rate,30-d mortality rate,and the number of operationsrelated to foreign body removal.RESULTS: The types of upper gastrointestinal foreign bodies included fish bones,drugs,shells,meat,metal,and animal bones.The locations of impacted foreign bodies were the upper esophagus(57.2%),mid esophagus(28.4%),stomach(10.8%),and lower esophagus(3.6%).The median size of the foreign bodies was 26.2 ± 16.7 mm.Among 194 patients,endoscopic removal was achieved in 189,and complications developed in 51 patients(26.9%).Significant complications associated with foreign body impaction and removal included deep lacerations with minor bleeding(n = 31,16%),ulcer(n = 11,5.7%),perforation(n = 3,1.5%),and abscess(n = 1,0.5%).Four patients underwent operations because of incomplete endoscopic foreign body extraction.In multivariate analyses,risk factors for endoscopic complications and failure were sharpness(HR = 2.48,95%CI: 1.07-5.72; P = 0.034) and a greater than 12-h duration of impaction(HR = 2.42,95%CI: 1.12-5.25,P = 0.025).CONCLUSION: In cases of longer than 12 h since foreign body ingestion or sharp-pointed objects,rapid endoscopic intervention should be provided in patients with ingested foreign bodies.     

Endoscopic management of impacted esophageal foreign bodies

There are many reports on the endoscopic management of ingested foreign bodies in the upper gastrointestinal tract, however, little is known about the management of a specific subset of esophageal foreign bodies – impacted esophageal foreign bodies (IEFBs), especially perforating esophageal foreign bodies (PEFBs). The aim of this retrospective study on 78 cases was to report experience and outcome in the endoscopic management of the IEFBs in Chinese patients. From January 2006 to July 2011, a total of 750 patients with suspected upper gastrointestinal foreign bodies were admitted to the endoscopy center. Among these 750 patients, 78 cases that met the defined criteria of IEFBs were retrospectively enrolled in the present study, including 12 cases (12/78, 15.4%) with PEFBs. The major types of IEFBs were poultry bones (35.9%) and fish bones (17.9%). Most of the IEFBs (80.8%) were located in the upper esophagus, as were two thirds (66.7%) of the PEFBs. Foreign‐body retrieval forceps were the most frequently used accessory devices. Extraction of IEFBs failed in eight patients (10.3%) during the endoscopic procedure. The difficult points in endoscopic management were PEFBs, IEFBs with sharp points, and those with impaction for more than 24 hours. IEFBs should be treated as early as possible, and their endoscopic management is safe and effective. Endoscopic management is the first choice for PEFBs when the duration of impaction is less than 24 hours and there are no abscesses outside of the esophageal tract as determined by a computed tomography scan.     

Endoscopic management of foreign bodies in the esophagus. Results of a retrospective series of 501 cases

We present the results of a retrospective study of endoscopic management (with flexible endoscopy) in 501 patients admitted for suspected ingestion of a foreign body between 1977 and 1997. The mean age of the patients was 55.73 19.38. Foreign bodies were found in the esophagus in 322 patients (64.3%) and endoscopic removal was successful in 307 (95.35%). More experienced endoscopists, with more than 45 cases, had a higher success rate (98.1%) than did less experienced endoscopists (87.9%) (p < 0.01). The most frequent type of foreign body in our series was meat bolus (32.8%). Underlying disease was found in 38.9%, and peptic stenosis was the most frequent. The only severe complication found was esophageal perforation in one patient (0.3%). Emergency flexible endoscopy is the most effective method for managing patients admitted for suspected ingestion of a foreign body and for the removal of foreign bodies located in the esophagus.     

Short‐ and long‐term effects of balloon dilatation on esophageal motility in achalasia

OBJECTIVE: To explore the effect of balloon dilatation on esophageal motility in patients with achalasia. METHODS: In 48 patients diagnosed with achalasia based on clinical observations, barium radio­graphy, endoscopy and esophageal manometry, the following parameters were evaluated before dilatation, and 4 and 12?24 weeks after dilatation: symptom score, maximal width of esophagus (MWE), lower esophageal sphincter pressure (LESP), lower esophageal sphincter relaxation rate (LESRR), and contraction amplitude of esophageal body. RESULTS: The symptom score and MWE decreased significantly after dilatation (P < 0.05). The LESP decreased (P < 0.05) and LESRR increased (P < 0.05) significantly 4 weeks and 12?24 weeks after dilatation. The percentages of patients with LESP <2.67 kPa were 45.41% before dilatation, and 82.48% and 85.87% 4 weeks and 12?24 weeks after dilatation, respectively (P < 0.05). The percentages of patients with LESRR ≥80% were 6.74% before dilatation, and 55.97% and 43.78% 4 weeks and 12?24 weeks after dilatation, respectively (P < 0.05). Peristaltic waves were not observed after dilatation in any patient. CONCLUSIONS: Balloon dilatation may significantly improve the symptoms of achalasia and reduce esophageal distention by decreasing LESP and increasing LESRR. The mechanism by which balloon dilatation increases LESRR needs to be further studied.     

Esophageal foreign body causing direct aortic injury.

Foreign bodies in the esophagus are uncommon causes of esophageal perforation. Many nonperforating cases are successfully managed by flexible gastroscopy. However, complicated foreign bodies such as those that result in esophageal perforation and vascular injury are best managed surgically. Gastroscopy remains the primary method of diagnosis. A case of a 59-year-old woman who developed retrosternal and intrascapular pain, odynophagia and hematemesis after eating fish is reported. Flexible gastroscopy showed arterial bleeding from the midthoracic esophagus. Computed tomography scan localized a 3 cm fish bone perforating the esophagus with surrounding hematoma. An aortogram did not reveal an actively bleeding aortoesophageal fistula. The fish bone was surgically removed and the patient recovered with no postoperative complications. This case illustrates the importance of early consideration for surgical intervention when confronted with a brisk arterial bleed from the esophagus with suggestive history of foreign body ingestion.     

Bougienage versus endoscopy for esophageal coin removal in children

BACKGROUND: Foreign body ingestion is a common pediatric problem. Coins are by far the most common ingested foreign bodies. When ingested coins become lodged in the esophagus, they may cause serious complications if they are not removed in a timely manner. Endoscopic removal is the preferred treatment in many pediatric centers as its safety and effectiveness are well established. OBJECTIVES: We performed this study to evaluate safety and effectiveness of an alternative method of managing esophageal coins, using bougienage technique. METHODS: Previously healthy children presenting to the local emergency room with uncomplicated, witnessed coin ingestion of less than 24 hours duration were prospectively recruited with an intent-to-treat analysis. A single oral passage of a Hurst bougie dilator was performed by a gastroenterologist to dislodge the esophageal coin into the stomach. If bougienage was successful (x-ray showing coin in the stomach), patients were discharged and instructions were given for monitoring stools until passage of the coin through anus was confirmed. If bougienage was unsuccessful, the child developed symptoms at any time or if a coin remained intragastric for 4 weeks, endoscopic removal was planned. Children whose parents declined to participate in the bougienage treatment received the standard endoscopic removal and their hospital records were used as controls. RESULTS: A total of 10 children were enrolled in this study, with a mean age of 3.2 years (11 mo to 10 y), 6 boys and 4 girls. All received little or no sedation. Nine children (90%) were successfully treated using bougienage, all of whom spontaneously passed the ingested coins, with a mean duration of 2.6 days (1 to 7 d) without subsequent intervention. A single case failed bougienage and underwent endoscopic removal. Three children declined bougienage treatment and underwent endoscopic removal. There were no reported minor or major adverse events with any of our cases. The mean health care cost for the hospital visit for bougienage treatment was $1210, compared with $3100 for the endoscopic removal (P<0.001). Furthermore, the mean time spent in the hospital from diagnosis to discharge was 2 hours for bougienage-treated patients compared with 8 hours for endoscopic treatment (P<0.001). CONCLUSIONS: Bougienage of impacted esophageal coins is an effective, safe, and more economic treatment modality for selected pediatric patients with uncomplicated coin ingestion. This simple technique may provide a valuable tool to emergency room physicians or primary care doctors especially when endoscopy is not readily available.     

Foreign body entrapment in the esophagus of healthy subjects—A manometric and scintigraphic study

Foreign body entrapment and mucosal injury caused by oral medications are increasingly reported to occur in the upper esophagus in apparently normal subjects. We performed esophageal manometry in 40 normal volunteers to determine whether a unique motility pattern in the upper third of the esophagus predisposes to entrapment of foreign bodies at this site; 18 normal volunteers also had transit scintigraphy of a gelatine capsule filled with a radionuclide. The esophageal body was divided into five consecutive segments starting proximally, with each segment corresponding to 20% of the total length. Amplitude, slope, and velocity of the esophageal contraction were markedly decreased in the second segment compared with the other segments. Entrapment and dissolution of a gelatine capsule occurred in 39% of volunteers in the proximal eosphagus correlating to the second segment, i.e., the segment with the lowest amplitude, slope, and velocity of esophageal contractions. The observation that wet swallows have greater amplitudes (P<0.01) and steeper slopes (P<0.05) than dry swallows explains why the occurrence of pill entrapment was reduced when taken with sufficient water. However, even with a water chaser of 120 mL, pill entrapment occurred at the second segment of the esophagus in 1 of 18 volunteers. The observed motility pattern in the proximal eosphagus provides a better explanation for the entrapment of foreign bodies at this site than compression of the esophagus by the left main stem bronchus, aortic arch, or left atrium as suggested by other investigators.     

Endoscopic management of foreign bodies in the upper gastrointestinal tract: a retrospective study of 1294 cases

Objective: To report our endoscopic outcomes and explore the effects of duration of impaction and anesthetic methods on the endoscopic removal of foreign bodies in the upper gastrointestinal tract.

Methods: All consecutive patients with suspected foreign body (FB) ingestion between January 2013 and June 2016 were enrolled. Demographic, clinical and endoscopic data were collected and analyzed.

Results: A total of 1294 patients aged seven months to 94 years were enrolled. Odynophagia (415 cases, 32.1%), FB sensation (340 cases, 26.3%) and sore throat (267 cases, 20.1%) were the most frequent complaints. The duration of FB impaction ranged from 4?h to over two years. Anatomically, foreign bodies were most commonly located in the esophagus (n?=?1025, 86.9%). Bony foreign bodies comprised the majority of identified foreign bodies. The most common underlying pathology was esophageal stricture (38 cases, 53.5%). Nearly half of the patients (49.9%) developed complications. As the duration of impaction increased, the success rate by endoscopy decreased (p?p?p?=?.793 and p?=?.085). Age?≥60, duration of impaction longer than one day, impaction in the esophagus, and sharp foreign bodies were identified as risk factors for complications.

Conclusions: Delayed flexible endoscopy in patients, especially elderly patients, with sharp FB impactions in the esophagus results in worse endoscopic outcomes. Endoscopic management under general anesthesia did not improve the therapeutic results compared with topical pharyngeal anesthesia.     

Effect of Cholecystectomy on Gastric and Esophageal Bile Reflux in Patients with Upper Gastrointestinal Symptoms

Epidemiologic data have shown that cholecystectomy is associated with a moderately increased risk of esophageal adenocarcinoma. The study objective was to evaluate the role of refluxed bile. A total of 696 patients with upper gastrointestinal symptoms were included in the study, of whom 55 had a history of cholecystectomy (CHE). Bilirubin exposure was measured in percent time above absorbance 0.25 in the stomach and above 0.14 in the esophagus. Total gastric and esophageal bilirubin exposure was similar in both groups. Supine gastric bile reflux was slightly increased after cholecystectomy (30.6 ± 30.2 vs. CHE: 37.1 ± 29.5, P < 0.05). In patients with erosive esophagitis or Barrett’s esophagus, there were differences in total gastric exposure (24.3 ± 22.6 vs. CHE: 36.7 ± 26.8, P < 0.05) but not in esophageal exposure. Cholecystectomy slightly augments bile reflux into the stomach without detectable differences in the esophagus. Therefore, increased esophageal bile reflux following cholecystectomy as a potential cause for the associated cancer risk could not be substantiated.     

Endoscopic management of foreign bodies in the upper-GI tract: experience with 1088 cases in China

BACKGROUND: Reports on endoscopic management of ingested foreign bodies of the upper-GI tract in China are scarce. OBJECTIVE: To report our experience and outcome in the management of ingestion of foreign bodies in Chinese patients. SETTING AND PATIENTS: Between January 1980 and January 2005, a total of 1088 patients (685 men and 403 women; age range, 1 day to 96 years old) with suspected foreign bodies were admitted to our endoscopy center. INTERVENTIONS: All patients underwent endoscopic procedure after admission. MAIN OUTCOME MEASUREMENTS: Demographic and endoscopic data, including age, sex, and referral sources of patients, types, number and location of foreign bodies, associated upper-GI diseases, endoscopic methods, and accessory devices for removal of foreign bodies were collected and analyzed. RESULTS: A total of 1090 foreign bodies were found in 988 (90.8%) patients. The types of foreign bodies varied greatly: mainly food boluses, coins, fish bones, dental prostheses, or chicken bones. The foreign bodies were located in the pharynx (n = 12), the esophagus (n = 577), the stomach (n = 441), the duodenum (n = 50), and the surgical anastomosis (n = 10). The associated GI diseases (n = 88) included esophageal carcinoma (33.0%), stricture (23.9%), diverticulum (15.9%), postgastrectomy (11.4%), hiatal hernia (10.2%), and achalasia (5.7%). A rat-tooth forceps and a snare were the most frequently used accessory devices. The success rate for foreign-body removal was 94.1% (930/988). CONCLUSIONS: Ingestion of foreign bodies is a common clinic problem in China. Endoscopy procedures are frequently performed, and a high proportion of patients with foreign bodies require endoscopic intervention.     

Acute therapy with intravenous omeprazole on caustic esophageal injury: a prospective case series

The ingestion of caustic substances may result in significant esophageal injury. There is no standard treatment protochol for esophageal injury and most patients are treated with a proton pump inhibitor or H2 antagonist. However, there is no clinical study evaluating the efficacy of omeprazole for caustic esophageal injury. A prospective study of 13 adult patients (>18 years of age) who were admitted to our hospital for caustic ingestion between May 2010 and June 2010 was conducted. Mucosal damage was graded using a modified endoscopic classification described by Zargar et al. Patients were treated with a proton pump inhibitor and maintained without oral intake until their condition was considered stable. Patients received omeprazole 80 mg in bolus IV, followed by continuous infusion of 8 mg/hour for 72 hours. A control endoscopy was performed 72 hours after admission. There was significant difference regarding endoscopic healing between the before and after omeprazole infusion (P = 0.004). There was no hospital mortality at the follow‐up. Omeprazole may effectively be used in the acute phase treatment of caustic esophagus injuries.     

Extraction des corps étrangers du tractus digestif haut par voie endoscopique : expérience d’un service de gastro-entérologie. À propos de 92 cas

Background

Foreign body ingestion is frequent in children and in specific high risk groups of adults such as those with underlying esophageal disease, prisoners, the mentally retarded and those with psychiatric illness.

Aims

To report the management and outcomes of patients with suspected ingestion of foreign bodies treated by endoscopic extraction.

Methods

Between 1985 and 2007 a total of 72 patients with 102 suspected foreign bodies underwent endoscopic procedures.

Results

A total of 92 foreign bodies were found in 62 patients. In the pediatric population, coins were the most frequent foreign body ingested (57 %) and in prisoners, metal objects were the most frequent (82 %). Bolus food impaction was located in the esophagus, coins and metallic foreign bodies in the stomach. Endoscopic extraction was possible in 92 % of cases without any complications.

Conclusion

Endoscopic removal of foreign bodies located in the upper gastro-intestinal tract is safe and successful.     

Esophageal foreign bodies.

Foreign body ingestion is a common occurrence in children and in specific high-risk groups of adults such as those with underlying esophageal disease, prisoners, the mentally retarded, and those with psychiatric illnesses. Although most foreign bodies pass through the gastrointestinal tract without difficulty, sharp, pointed, and elongated foreign bodies are associated with a greater risk of perforation, vascular penetration, and other complications. Foreign body ingestion is usually diagnosed based on a history of ingestion given by the patient or an observer. However, children and impaired adults may be unable to give an accurate history, and a high index of suspicion must be maintained in these groups. Dysphagia and odynophagia are the usual symptoms of foreign body impaction in the esophagus. Respiratory symptoms due to compression of the adjacent trachea are also common in younger children and are occasionally the presenting symptom in adults. The preferred method of removal of esophageal foreign bodies is extraction with the flexible endoscope. This may be accomplished in both adults and children with the use of conscious sedation rather than general anesthesia. The availability of grasping instruments specifically designed for foreign body removal and snares greatly facilitates endoscopic extraction. An overtube conveys all of the advantages of the rigid esophagoscope to the flexible endoscope, enabling extraction of sharp and pointed foreign bodies while protecting the mucosa from injury. Adherence to the general principles of foreign body removal and proper preparation result in successful removal rates as high as 98%, with minimal or no complications. Nonendoscopic methods of removal are associated with increased risks of perforation and aspiration and generally should be avoided, with the exception of a trial of intravenous glucagon. Surgical removal is rarely indicated except in the event of perforation or other foreign body complications.     

Esophageal foreign bodies: Types and techniques for removal

Opinion statement Patients with esophageal foreign bodies require prompt diagnosis and therapy. The first tasks are to determine the type of object, time since ingestion, location of the object, and the likelihood of associated complications. Patients who have evidence of complete esophageal occlusion or who have ingested a sharp or pointed object require urgent treatment due to the increased risk of complications. Button batteries are particularly injurious in the esophagus and should be removed immediately. Coins in the esophagus should also be removed; however, a brief period of observation is appropriate for coins in the distal esophagus, as some will pass spontaneously. Flexible endoscopy is the therapeutic modality of choice for most patients. The key principles for endoscopic management of esophageal foreign bodies are to protect the airway, to maintain control of the object during extraction, and to avoid causing additional damage. Endotracheal intubation is sometimes necessary, especially in younger children and those at higher risk for aspiration. The use of devices such as an esophageal overtube and a latex protector hood may facilitate safer extraction of sharp/pointed objects. Patients with food impactions usually require treatment of an associated structural lesion of the esophagus.     

Foreign bodies of the upper gastrointestinal tract

This is a retrospective review of our experience with fiberendoscopic management of 40 separate episodes of foreign body ingestion. Eighteen patients swallowed a food bolus which impacted in the esophagus. Seventy-eight percent of these patients had an esophageal stenosis. Sixteen patients were involved in 22 episodes of true foreign body ingestion. Fiberendoscopic management was successful in 92% of food impactions and 76% of true foreign bodies. In our experience, fiberendoscopic removal is a safe procedure with an 83% overall success rate. It is the method of choice in the management of esophageal and gastric foreign bodies.     

Clinical remission following endoscopic placement of retrievable,fully covered metal stents in patients with esophageal achalasia

Metal stents may represent an alternative therapy in the treatment of achalasia. We therefore evaluated the effectiveness of retrievable, fully covered metal stents in patients with achalasia. Fifty‐nine patients with achalasia were treated with retrievable, fully covered metal stents. Symptoms using a global symptom score (0–10), lower esophageal sphincter (LES) resting pressure, LES relaxation, and simultaneous contraction of the esophagus were analyzed before and 1 week and 1 month after intervention. Complications and treatment outcomes were followed up at 6, 12, 18, and 24 months postoperatively. Stent placement was successful, and clinical symptoms resolved (P < 0.01) in all patients. Regurgitation, dysphagia and chest pain improved significantly (all P < 0.01). Therapy improved LES resting pressure (51.4 ± 9.7 mmHg pretherapy vs. 20.9 ± 8.1 mmHg post‐therapy), LES relaxation (58.1 ± 17.1% pretherapy vs. 84.5 ± 18.9% post‐therapy), and simultaneous contraction of the esophagus (36.1 ± 8.6% pretherapy vs. 69.4 ± 23.1% post‐therapy) 1 month after stent placement (all P < 0.01). The cumulative clinical remission rates 6, 12, 18, 24, 30, and 36 months after stent removal were 90.9%, 81.8%, 76.4%, 69.1%, 65.5%, and 49.1%, respectively. All patients tolerated stent placement. Twelve patients (25.5%) complained of substernal pain and five (10.6%) had substernal burning. Stents migrated in four patients (8.5%). Insertion of retrievable, fully covered metal stents is an effective and safe treatment in patients with achalasia.     

Pathogenesis and outcomes of traumatic injuries of the esophagus

Traumatic injury of the esophagus is extremely uncommon. The aims of this study were to use the Pennsylvania Trauma Outcome Study (PTOS) database to identify clinical factors predictive of esophageal trauma, and to report the morbidity and mortality of this injury. A cross‐sectional review of patients presenting to 20 Level I trauma centers in Pennsylvania from 2004 to 2010 was performed. We compared clinical and demographic variables between patients with and without esophageal trauma both prior to and after arrival in the emergency room (ER). Primary mechanism of injury and clinical outcomes were analyzed. There were 231 694 patients and 327 (0.14%) had esophageal trauma. Patients with esophageal trauma were considerably younger than those without this injury. The risk of esophageal trauma was markedly increased in males (odds ratio [OR] = 2.62 [CI 1.98–3.47]). The risk was also increased in African Americans (OR = 4.61 [CI 3.65–5.82]). Most cases were from penetrating gunshot and stab wounds. Only 34 (10.4%) of esophageal trauma patients underwent an upper endoscopy; diagnosis was usually made by CT, surgery, or autopsy. Esophageal trauma patients were more likely to require surgery (35.8% vs. 12.5%; P < 0.001). Patients with esophageal trauma had a substantially higher mortality than those without the injury (20.5% vs. 1.4%; P < 0.005). In logistic regression modeling, traumatic injury of the esophagus (OR = 3.43 [2.50–4.71]) and male gender (OR = 1.52 [1.46–1.59]) were independently associated with mortality. For those patients with esophageal trauma, there was an association between trauma severity and mortality (OR = 1.10 [1.07–1.12]) but not for undergoing surgery within the first 24 hours of hospitalization (OR = 0.84; 0.39–1.83). Our study on traumatic injury of the esophagus is in concordance with previous studies demonstrating that this injury is rare but carries considerable morbidity (～46%) and mortality (～20%). The injury has a higher morbidity and mortality when the thoracic esophagus is involved compared to the cervical esophagus alone. The injury most commonly occurs in younger, Black males suffering gunshot wounds. Efforts to control gun violence in Pennsylvania are of paramount importance.     

Endoscopic removal of foreign bodies in children

The ingestion of foreign bodies such as coins, fish bones, plastic toy parts, batteries, and needles is common in children. Although the majority of ingested foreign bodies pass through the gastrointestinal tract unaided, some children require either nonsurgical or surgical intervention. The medical records of children who presented to the pediatric emergency department of a single tertiary referral center between December 2001 and May 2006 were reviewed. A total of 87 patients underwent an endoscopic procedure because of suspected foreign body ingestion and foreign bodies were identified by endoscopy in 74 patients (85.1%). The mean age of these 74 patients was 3.4 years (range, 6 months to 13 years). The most common site of foreign body lodgement was the esophagus (n = 38, 51.4%); other sites included the stomach (n = 33, 44.6%) and duodenum (n = 3, 4.0%). The types of foreign bodies included coins (n = 42, 56.8%), button batteries (n = 16, 21.6%), sharp objects (n = 9, 12.2%), chicken bones (n = 2, 2.7%) and others (n = 5, 6.7%). Only two foreign bodies (button batteries) in the duodenum could not be removed successfully by endoscopy. Instead, they were moved into the intestine and then eliminated spontaneously the following day. There were no major complications caused by foreign body ingestion or endoscopic procedures. The outcome of all patients was uneventful without morbidity or mortality. In our experience, endoscopic removal of foreign bodies under general anesthesia is an effective and safe method in children; the method also prevents erosion and perforation of the gastrointestinal tract.     

Esophageal hematoma

Hematoma of the esophagus is an uncommon condition. Patients often present with acute odynophagia or retrosternal pain, which may be confused with other diagnoses. We report herein two patients with esophageal hematoma caused by foreign body ingestion. Conservative treatment resulted in complete resolution. The literature is reviewed for the etiology, clinical features and management of this condition.     

Methylene Blue Staining and Endoscopic Ultrasound Evaluation of Barrett's Esophagus with Low-Grade Dysplasia

This study was performed to determine if either methylene blue staining or endoscopic ultrasound helped direct biopsies in patients with a history of Barrett's esophagus with low-grade dysplasia. Patients underwent radial endoscopic ultrasound scanning to measure esophageal wall thickness, followed by endoscopy with methylene blue staining and biopsies. Mean esophageal wall thickness for squamous mucosa (2.3 ± 0.2 mm), nondysplastic Barrett's (2.6 ± 0.2 mm), and Barrett's with dysplasia (2.9 ± 0.3 mm) were similar. With staining, Barrett's mucosa stained blue more often than gastric epithelium (68% vs 15%, respectively; P < 0.001). The sensitivity and specificity for strong staining detecting Barrett's were 68% and 85%, respectively. Barrett's with low-grade dysplasia stained blue less frequently (52%) than nondysplastic Barrett's (74%; P < 0.05), but the positive predictive value for poor staining indicating dysplasia was 41%. Endoscopic ultrasound was not helpful in directing biopsies in these patients. The utility of methylene blue for detecting dysplasia needs further investigation.